Bill Text: OR SB163 | 2013 | Regular Session | Introduced

Oregon Senate Bill 163 (Prior Session Legislation)

Bill Title: Relating to prescription drug coverage under health benefit plans; declaring an emergency.

Spectrum: Committee Bill

Status: (Failed) 2013-07-08 - In committee upon adjournment. [SB163 Detail]

Download: Oregon-2013-SB163-Introduced.html



     77th OREGON LEGISLATIVE ASSEMBLY--2013 Regular Session

NOTE:  Matter within  { +  braces and plus signs + } in an
amended section is new. Matter within  { -  braces and minus
signs - } is existing law to be omitted. New sections are within
 { +  braces and plus signs + } .

LC 1275

                         Senate Bill 163

Printed pursuant to Senate Interim Rule 213.28 by order of the
  President of the Senate in conformance with presession filing
  rules, indicating neither advocacy nor opposition on the part
  of the President (at the request of Senate Interim Committee on
  Health Care, Human Services and Rural Health Policy for Pfizer)

                             SUMMARY

The following summary is not prepared by the sponsors of the
measure and is not a part of the body thereof subject to
consideration by the Legislative Assembly. It is an editor's
brief statement of the essential features of the measure as
introduced.

  Imposes restrictions on fail-first protocols for coverage of
prescription drugs by health benefit plans.
  Declares emergency, effective on passage.

                        A BILL FOR AN ACT
Relating to prescription drug coverage under health benefit
  plans; creating new provisions; amending ORS 750.055 and
  750.333; and declaring an emergency.
Be It Enacted by the People of the State of Oregon:
  SECTION 1.  { + Section 2 of this 2013 Act is added to and made
a part of the Insurance Code. + }
  SECTION 2.  { + (1) As used in this section:
  (a) 'Fail-first protocol' means a method of managing the
utilization of prescription drugs in which an insured must first
try an alternative drug for a specific condition and find the
alternative to be ineffective before the insurer will cover the
drug prescribed by the insured's health care provider or a drug
that is generically equivalent to the drug prescribed by the
insured's health care provider.
  (b) 'Generically equivalent' means:
  (A) Having the same active chemical ingredients of the same
strength, quantity and dosage form as the prescribed drug;
  (B) Having the generic drug name as determined by the United
States Adopted Names Council; and
  (C) Accepted by the United States Food and Drug Administration
as having the same chemical ingredients as the prescribed drug.
  (c) 'Health benefit plan' has the meaning given that term in
ORS 743.730.
  (d) 'Step therapy' is a type of fail-first protocol in which an
insurer will not cover a drug prescribed by an insured's health
care provider or a drug that is generically equivalent to the
drug prescribed by the health care provider unless an insured has
first tried a series of less costly or more safe drugs and those
drugs have not been effective or have caused an adverse reaction
or other physical harm to the insured.
  (2) A fail-first protocol required in a health benefit plan for
coverage of prescription drugs for the treatment of pain:
  (a) Must allow the prescribing health care provider to
establish the duration of each step in a step therapy protocol or
the total duration of any fail-first protocol;
  (b) May not require a patient to first fail on more than two
alternative drugs;
  (c) May not require prior authorization after the insured has
followed the fail-first protocol if the health care provider
notes in the patient's chart that the patient has followed the
fail-first protocol; and
  (d) May not require a pharmacist to contact the insurer before
filling a prescription subject to the fail-first protocol if the
health care provider notes on the prescription that the
fail-first protocol has been followed.
  (3) This section does not prohibit an insurer from imposing a
copayment or deductible or a maximum coverage limitation for
prescription drugs if the copayment, deductible or limitation are
set forth in the summary of benefits and explanation of coverage
and the health insurance policy or certificate and have been
approved by the Department of Consumer and Business Services
under ORS 742.003 or 743.010.
  (4) This section does not require an insurer to cover
prescription drugs that are not in the insurer's formulary or
prohibit an insurer from substituting generically equivalent
drugs. + }
  SECTION 3. ORS 750.055, as amended by section 3, chapter 21,
Oregon Laws 2012, is amended to read:
  750.055. (1) The following provisions of the Insurance Code
apply to health care service contractors to the extent not
inconsistent with the express provisions of ORS 750.005 to
750.095:
  (a) ORS 705.137, 705.139, 731.004 to 731.150, 731.162, 731.216
to 731.362, 731.382, 731.385, 731.386, 731.390, 731.398 to
731.430, 731.428, 731.450, 731.454, 731.488, 731.504, 731.508,
731.509, 731.510, 731.511, 731.512, 731.574 to 731.620, 731.592,
731.594, 731.640 to 731.652, 731.730, 731.731, 731.735, 731.737,
731.750, 731.752, 731.804, 731.844 to 731.992, 731.870 and
743.061.
  (b) ORS 732.215, 732.220, 732.230, 732.245, 732.250, 732.320,
732.325 and 732.517 to 732.592, not including ORS 732.582.
  (c) ORS 733.010 to 733.050, 733.080, 733.140 to 733.170,
733.210, 733.510 to 733.680 and 733.695 to 733.780.
  (d) ORS chapter 734.
  (e) ORS 742.001 to 742.009, 742.013, 742.061, 742.065, 742.150
to 742.162, 742.400, 742.520 to 742.540, 743.010, 743.013,
743.018 to 743.030, 743.050, 743.100 to 743.109, 743.402,
743.472, 743.492, 743.495, 743.498, 743.499, 743.522, 743.523,
743.524, 743.526, 743.527, 743.528, 743.529, 743.549 to 743.552,
743.560, 743.600 to 743.610, 743.650 to 743.656, 743.764,
743.804, 743.807, 743.808, 743.814 to 743.839, 743.842, 743.845,
743.847, 743.854, 743.856, 743.857, 743.858, 743.859, 743.861,
743.862, 743.863, 743.864, 743.894, 743.911, 743.912, 743.913,
743.917, 743A.010, 743A.012, 743A.020, 743A.034, 743A.036,
743A.048, 743A.058, 743A.062, 743A.064, 743A.065, 743A.066,
743A.068, 743A.070, 743A.080, 743A.084, 743A.088, 743A.090,
743A.100, 743A.104, 743A.105, 743A.110, 743A.140, 743A.141,
743A.144, 743A.148, 743A.160, 743A.164, 743A.168, 743A.170,
743A.175, 743A.184, 743A.185, 743A.188, 743A.190 and 743A.192 and
section 2, chapter 21, Oregon Laws 2012 { + , and section 2 of
this 2013 Act + }.
  (f) The provisions of ORS chapter 744 relating to the
regulation of insurance producers.
  (g) ORS 746.005 to 746.140, 746.160, 746.220 to 746.370,
746.600, 746.605, 746.607, 746.608, 746.610, 746.615, 746.625,
746.635, 746.650, 746.655, 746.660, 746.668, 746.670, 746.675,
746.680 and 746.690.

  (h) ORS 743A.024, except in the case of group practice health
maintenance organizations that are federally qualified pursuant
to Title XIII of the Public Health Service Act unless the patient
is referred by a physician associated with a group practice
health maintenance organization.
  (i) ORS 735.600 to 735.650.
  (j) ORS 743.680 to 743.689.
  (k) ORS 744.700 to 744.740.
  (L) ORS 743.730 to 743.773.
  (m) ORS 731.485, except in the case of a group practice health
maintenance organization that is federally qualified pursuant to
Title XIII of the Public Health Service Act and that wholly owns
and operates an in-house drug outlet.
  (2) For the purposes of this section, health care service
contractors shall be deemed insurers.
  (3) Any for-profit health care service contractor organized
under the laws of any other state that is not governed by the
insurance laws of the other state is subject to all requirements
of ORS chapter 732.
  (4) The Director of the Department of Consumer and Business
Services may, after notice and hearing, adopt reasonable rules
not inconsistent with this section and ORS 750.003, 750.005,
750.025 and 750.045 that are deemed necessary for the proper
administration of these provisions.
  SECTION 4. ORS 750.333, as amended by section 4, chapter 21,
Oregon Laws 2012, is amended to read:
  750.333. (1) The following provisions of the Insurance Code
apply to trusts carrying out a multiple employer welfare
arrangement:
  (a) ORS 731.004 to 731.150, 731.162, 731.216 to 731.268,
731.296 to 731.316, 731.324, 731.328, 731.378, 731.386, 731.390,
731.398, 731.406, 731.410, 731.414, 731.418 to 731.434, 731.454,
731.484, 731.486, 731.488, 731.512, 731.574 to 731.620, 731.640
to 731.652, 731.804 to 731.992 and 743.061.
  (b) ORS 733.010 to 733.050, 733.140 to 733.170, 733.210,
733.510 to 733.680 and 733.695 to 733.780.
  (c) ORS chapter 734.
  (d) ORS 742.001 to 742.009, 742.013, 742.061 and 742.400.
  (e) ORS 743.028, 743.053, 743.499, 743.524, 743.526, 743.527,
743.528, 743.529, 743.530, 743.560, 743.562, 743.600, 743.601,
743.602, 743.610, 743.730 to 743.773 (except 743.760 to 743.773),
743.801, 743.804, 743.807, 743.808, 743.814 to 743.839, 743.842,
743.845, 743.847, 743.854, 743.856, 743.857, 743.858, 743.859,
743.861, 743.862, 743.863, 743.864, 743.894, 743.912, 743.917,
743A.012, 743A.020, 743A.034, 743A.052, 743A.064, 743A.065,
743A.080, 743A.100, 743A.104, 743A.110, 743A.144, 743A.170,
743A.175, 743A.184 and 743A.192 and section 2, chapter 21, Oregon
Laws 2012 { + , and section 2 of this 2013 Act + }.
  (f) ORS 743A.010, 743A.014, 743A.024, 743A.028, 743A.032,
743A.036, 743A.040, 743A.048, 743A.058, 743A.066, 743A.068,
743A.070, 743A.084, 743A.088, 743A.090, 743A.105, 743A.140,
743A.141, 743A.148, 743A.168, 743A.180, 743A.185, 743A.188 and
743A.190. Multiple employer welfare arrangements to which ORS
743.730 to 743.773 apply are subject to the sections referred to
in this paragraph only as provided in ORS 743.730 to 743.773.
  (g) Provisions of ORS chapter 744 relating to the regulation of
insurance producers and insurance consultants, and ORS 744.700 to
744.740.
  (h) ORS 746.005 to 746.140, 746.160 and 746.220 to 746.370.
  (i) ORS 731.592 and 731.594.
  (j) ORS 731.870.
  (2) For the purposes of this section:
  (a) A trust carrying out a multiple employer welfare
arrangement shall be considered an insurer.

  (b) References to certificates of authority shall be considered
references to certificates of multiple employer welfare
arrangement.
  (c) Contributions shall be considered premiums.
  (3) The provision of health benefits under ORS 750.301 to
750.341 shall be considered to be the transaction of health
insurance.
  SECTION 5.  { + Section 2 of this 2013 Act and the amendments
to ORS 750.055 and 750.333 by sections 3 and 4 of this 2013 Act
apply to policies or certificates issued or renewed on or after
the effective date of this 2013 Act. + }
  SECTION 6.  { + This 2013 Act being necessary for the immediate
preservation of the public peace, health and safety, an emergency
is declared to exist, and this 2013 Act takes effect on its
passage. + }
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